Evidence-Based Reviews

‘I’m as ugly as the elephant man’: How to recognize and treat body dysmorphic disorder

Body dysmorphic disorder is a common and severe psychiatric malady that often masquerades as other disorders and is usually missed in clinical practice. If recognized and treated appropriately, a majority of patients will improve.

A 52-year-old man becomes intoxicated with alcohol so he can lie in his backyard and get a tan. Convinced that his skin is too pale and that he looks “like a ghost,” he is so self-conscious about how he looks that he can’t go outside without drinking excessively.

An attractive 23-year-old woman dropped out of the 10th grade because of her “hideous” appearance and has hidden in her bedroom in her parents’ house ever since. She leaves her room no more than once a month, only after covering her face with a veil, not letting even her family see her face.

A middle-aged man cuts his nose open with a razor blade, trying to remove his nasal cartilage and replace it with chicken cartilage, in the desired shape.

These patients have body dysmorphic disorder (BDD), a somatoform disorder that the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV) defines as a preoccupation with an imagined defect in appearance; if a slight physical anomaly is present, the person's concern is markedly excessive. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning that are not attributed to another mental disorder.

Most of us are dissatisfied with some aspect of how we look. In fact, more than half of all women and nearly half of all men in the United States are dissatisfied with their overall appearance.1 As the preceding cases illustrate, however, BDD does not consist simply of normal appearance concerns.

BDD is a relatively common disorder2 (Box 1) that occurs in children as well as adults. It usually begins during the early teenage years.2 BDD has been described around the world for more than a century.3 It causes notable distress and impaired functioning, and can lead to suicide.4 This disorder typically goes undiagnosed in clinical settings, however, in part because many patients are too embarrassed and ashamed to discuss their symptoms with their physicians unless specifically asked.2,5 BDD often masquerades as other psychiatric disorders, and misdiagnosis appears common6 (Table 1). Diagnosing BDD is usually straightforward, however, and can be achieved using the questions in Box 2.4 Clues to the presence of BDD are presented in Box 3; patients who present with any of them should be carefully evaluated for BDD.

1 in 7 to nearly half of outpatients with atypical major depression (14%-42%)

1 in 8 to 9 outpatients with social phobia (11%-13%)

1 in 3 to 12 outpatients with obsessive-compulsive disorder (8%-37%)

1 in 8 patients seeking dermatologic treatment (12%)

1 in 7 to 15 patients seeking cosmetic surgery (6%-15%)

Nearly 1 in 100 to more than 1 in 50 people in the general population (0.7%-2.3%)

Perceptions of patients with BDD

Individuals with BDD obsess that there is something wrong with their appearance when in fact they look fine; the perceived flaw is actually minimal or nonexistent.7 Prior to treatment, insight is usually poor or absent, however, so that most patients are convinced or fairly certain that they look abnormal.2,8 They may describe the perceived flaw as unattractive or deformed, or they may even say that they look like a freak, a monster, or the “elephant man” (Box 4). Individuals with this disorder think about the perceived appearance flaws, on average, for 3 to 8 hours a day, and they usually find the thoughts difficult to resist or control.9 Diagnostic errors that cause BDD to be missed

Table 1

Diagnostic errors that cause BDD to be missed

Misdiagnosis

Diagnostic error

How to avoid the error

Depression

The depressive symptoms that often coexist with BDD are diagnosed and BDD is missed; or BDD symptoms are considered a symptom of depression. In the author’s clinical experience, this is the most common diagnostic error.

Look for BDD in all depressed patients; appearance concerns may not be simply a symptom of depression.

Social phobia

Social anxiety is a common consequence of BDD, which may be misdiagnosed as social phobia or avoidant personality disorder.

Explore the cause of social anxiety or avoidance and determine whether it is secondary to BDD.

Agoraphobia

Many BDD patients are housebound at some point, which may be misdiagnosed as agoraphobia.

Explore the cause of avoidance and determine whether it is due to BDD.

OCD

BDD’s prominent obsessions and compulsive behaviors may be misdiagnosed as OCD.

If the obsessions and behaviors focus on physical appearance, BDD is the more accurate diagnosis.

Panic disorder

Panic attacks that occur when looking in the mirror or experiencing referential thinking can be misdiagnosed as panic disorder.

Determine whether panic attacks have BDD-related triggers; if so, BDD should be diagnosed.

Trichotillomania

Some BDD patients remove their body, head, or facial hair in an effort to improve their appearance, which may be misdiagnosed as trichotillomania.

Determine whether hair removal reflects thoughts that the hair does not look right and is intended to improve appearance; if so, the patient may have BDD.

Schizophrenia.

Because BDD beliefs are often delusional, and many patients have referential thinking, occasionally patients are misdiagnosed with Schizophrenia

If psychotic symptoms are largely limited to a nonbizarre delusional belief about one’s physical appearance and/or related delusions of reference, BDD is the more accurate diagnosis.

Although repetitive behaviors are not part of BDD’s diagnostic criteria, virtually all patients perform such behaviors, usually in an attempt to improve, hide, examine, or be reassured about the perceived flaw.7,9 (See Box 3 for a partial listing.) These behaviors are usually time-consuming, occurring for many hours a day, and, like the preoccupations, are typically difficult to resist or control. With the exception of camouflaging, however, they often do not diminish appearance concerns. In fact, some of them (e.g., mirror checking) may actually increase anxiety about the perceived flaw.

Comorbidity is common in patients seen in clinical settings.2,8 Major depression is the most frequent comorbid disorder, which often appears secondary to BDD.10 Other common comorbidities include substance-use disorders, obsessive-compulsive disorder (OCD), social phobia, and personality disorders (most often, avoidant personality disorder).

Individuals with BDD are distressed over their appearance, many to the point of contemplating, attempting, or completing suicide.4,5 Nearly one quarter of patients seen in a clinical setting have attempted suicide.9 Although some patients appear to function reasonably well, they usually function below their capacity—for example, by avoiding social situations or meetings at work where others will see them. Others are completely incapacitated by their BDD symptoms, unable to work or socialize, and may be housebound for years.2,8,9 In a study that used the SF-36 to measure health-related quality of life, outpatients with BDD scored notably worse in all mental health domains than did the general U.S. population and patients with depression, type II diabetes, or a recent myocardial infarction.2

Are you worried about your appearance in any way? If yes: What is your concern? OR Are you unhappy with how you look? If yes: What is your concern?

Does this concern preoccupy you? That is, do you think about it a lot and wish you could worry about it less? OR If you add up all the time you spend each day thinking about your appearance, how much time would you estimate you spend?

What effect has this preoccupation with your appearance had on your life? Has it:

BDD is diagnosed in patients who 1) are concerned about a minimal or nonexistent appearance flaw, 2) are preoccupied with the “flaw” (e.g., think about it for at least an hour a day), and 3) experience clinically significant distress or impairment in functioning as a result of their concern.

Establish trust. It is important to convey that you take the patient’s appearance concerns seriously. Many patients with BDD fear being considered silly or vain and do not divulge their symptoms. It is usually best to avoid reassuring patients that they look fine, since they usually do not believe the reassurance and can interpret it as trivializing their concerns.

Provide psychoeducation. Explain to patients that they have a relatively common and treatable body image disorder. To decrease the patient’s reluctance to accept the diagnosis and treatment, it can be helpful to emphasize the excessive preoccupation, distress, and other problems their symptoms are causing. Discussions about whether the defect is “real” are usually fruitless, unless the patient already has good insight, which is rare. Several educational books and Web sites for patients are available. See Related Resources.

Target BDD symptoms in treatment. Ignoring BDD symptoms and focusing treatment on other symptoms only may be unsuccessful because effective treatment for BDD differs in some important ways from that of most other psychiatric disorders, such as depression.10 It appears, for example, that non-selective serotonin reuptake inhibitor (SSRI) antidepressants are generally ineffective for BDD, unless used at higher SSRI doses than are often needed for depression. BDD symptoms also do not necessarily improve in concert with symptoms of other disorders, such as depression or OCD.10

Avoid nonpsychiatric medical treatment. Although no one can predict how an individual patient will respond to nonpsychiatric treatment, (e.g., surgery or dermatologic treatment), explain that as best we know, such treatment usually appears to be ineffective for BDD and even can make the symptoms worse.11

Which psychopharmaceuticals should you consider?

Although BDD’s response to pharmacotherapy has received far less investigation than that of many other psychiatric disorders, research on this treatment approach has dramatically increased in recent years. The following strategies are suggested on the basis of evidence from controlled studies, open-label trials, and the author’s clinical experience (Figure 1):2,6,8,12-17

An early refill request for psychostimulants for your college-age patient

﻿Mr. R, age 18, who has been taking amphetamine/dextroamphetamine, 10 mg/d, twice a day, for attention-deficit/hyperactivity disorder since he was age 10, comes to see you shortly after beginning college asking to refill earlier than usual. He says his symptoms are worse since beginning college and he is finding it difficult to focus in class and keep up with the heavy course work. He says he has been taking an extra 10 mg when he “needs the extra boost.” He asks for an early refill and increased dosage. How do you proceed?

Switch to an extended release formulation and increase the dosage to 30 mg/d

Switch to lisdexamfetamine, 30 mg/d

Prescribe amphetamine/dextroamphetamine, 10 mg, on an as-needed basis

Tell Mr. R to take his current prescription as prescribed and discuss the dangers of stimulant abuse. Reassess his symptoms at the next visit.